Quotation Estimate Dentist in Canada Toronto –Free Word Template Download with AI
245 King Street West, Suite 1200, Toronto, Ontario, Canada M5V 1J9
Phone: (416) 555-0187 | Email: [email protected]
College of Dentists of Ontario License No. 48291
Dentist Canada Toronto
Quotation EstimatePrepared For (Patient)
Name: Margaret A. Thompson
Address: 88 Rosedale Avenue, Toronto, ON M4P 1A2, Canada
Phone: (416) 555-3321
Insurance: Sun Life Dental Plan #SL-7742-901
Member ID: 8821-4456-0093
Quotation Details
Quotation No.: QTE-2025-04187
Date Issued: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Attending Dentist: Dr. James Okafor, DDS, FICOI
Location: Toronto, Ontario, Canada
Dear Ms. Thompson,
Thank you for choosing Lakeshore Dental Care Centre, a trusted Dentist practice serving the greater Canada Toronto metropolitan area. This Quotation Estimate has been prepared following your comprehensive dental examination and diagnostic imaging completed on June 5, 2025. The following Quotation Estimate outlines the recommended treatment plan, associated costs, and applicable insurance coverage for your dental care needs. All pricing reflects current Canada Toronto dental fee schedules as regulated by the College of Dentists of Ontario.
| # | Dental Procedure / Service | ADA Code | Qty | Unit Price (CAD) | Subtotal (CAD) | Est. Ins. Cov. |
|---|---|---|---|---|---|---|
| 1 | Comprehensive Periodontal Scaling & Root Planing (Full Mouth) | D4346 | 1 | $685.00 | $685.00 | 50% |
| 2 | Intraoral Digital X-Ray (Full Series – 14 Views) | D0210 | 1 | $210.00 | $210.00 | 80% |
| 3 | Composite Resin Filling – Posterior (Tooth #19) | D2392 | 1 | $320.00 | $320.00 | 50% |
| 4 | Composite Resin Filling – Anterior (Tooth #8) | D2391 | 1 | $275.00 | $275.00 | 50% |
| 5 | Porcelain Crown – Molar (Tooth #30), including temporary crown | D2740 | 1 | $1,450.00 | $1,450.00 | 50% |
| 6 | Professional Prophy (Cleaning) & Polishing | D1110 | 1 | $145.00 | $145.00 | 100% |
| 7 | Fluoride Varnish Application (Adult) | D1206 | 1 | $55.00 | $55.00 | 100% |
| 8 | Follow-Up Consultation & Treatment Review (30 min) | D0010 | 1 | $95.00 | $95.00 | 100% |
| Subtotal (CAD) | $3,235.00 |
| HST (13%) – Ontario, Canada | $420.55 |
| Estimated Insurance Reimbursement | ($1,282.50) |
| Estimated Patient Responsibility | $2,373.05 |
Terms & Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After this period, pricing may be adjusted to reflect updated Canada Toronto dental fee schedules or changes in material costs.
- All prices are quoted in Canadian Dollars (CAD) and are subject to the 13% Harmonized Sales Tax (HST) applicable in the Province of Ontario, Canada Toronto region, as mandated by the Canada Revenue Agency.
- Estimated insurance coverage percentages are based on the Sun Life Dental Plan benefits provided by the patient. Actual reimbursement is determined solely by the insurance carrier and may vary. This Dentist practice does not guarantee insurance payment amounts.
- The porcelain crown (Item 5) requires a minimum of two (2) visits spaced approximately two weeks apart. The temporary crown is included in the quoted price. If the permanent crown must be remade due to patient-related factors, an additional fee of $180.00 will apply.
- Payment is due at the time of service. This Dentist office in Canada Toronto accepts Visa, Mastercard, Interac e-Transfer, and direct deposit. A 2% surcharge applies to credit card transactions exceeding $100.00, in compliance with Ontario merchant regulations.
- Should any additional procedures become necessary during treatment that were not identified during the initial examination, a revised Quotation Estimate will be provided and signed by the patient before any further work commences.
- This Quotation Estimate does not constitute a binding contract for treatment. The patient retains the right to decline any or all recommended procedures. The Dentist reserves the right to modify the treatment plan based on clinical findings at the time of procedure.
- All treatment will be performed in accordance with the standards set by the College of Dentists of Ontario and the Health Professions Act of Ontario. This practice is fully licensed to operate as a Dentist clinic within the City of Toronto, Canada.
- Records of this Quotation Estimate and all subsequent treatment documentation will be retained in the patient's permanent dental file for a minimum of seven (7) years, as required by Ontario health records legislation.
- For any questions regarding this Quotation Estimate, please contact our front desk at (416) 555-0187 or visit us at 245 King Street West, Toronto, ON, Canada. Our office is open Monday through Friday, 8:00 AM to 6:00 PM, and Saturday 9:00 AM to 2:00 PM.
Prepared by (Dentist):
Dr. James Okafor, DDS, FICOI
Lakeshore Dental Care Centre
Toronto, Ontario, Canada
Signature: ___________________________
Date: ___________________________
Accepted by (Patient):
Ms. Margaret A. Thompson
Toronto, Ontario, Canada
Signature: ___________________________
Date: ___________________________
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